Tischa van der Cammen is a Consultant Geriatrician and Carolyn Sterkeis a public health researcher. Both are based at the Erasmus University Medical Center in Rotterdam, Netherlands and have recently published a paper in Age and Ageing journal.
Drug treatment has brought many benefits for older patients. For example, the treatment of hypertension in patients aged over 80 led to a major reduction in stroke and mortality, as was shown in the HYVET study.
As people age, diseases may accumulate, and hence older patients usually are prescribed several drugs at the same time. It is ‘rule rather than exception’ that patients above age 75 use 4 or more drugs, this is called polypharmacy. There are a variety of definitions for polypharmacy – in the UK it is generally 4 or more prescribed medicines – as specified by Department of health and Rollason.
Inappropriate poly-pharmacy in older patients may lead to negative health impacts in the form of increased side-effects and drug-drug interactions, and can be a contributing factor towards falls or cognitive decline. This has been highlighted in recent Cochrane and King’s Fund publications, these studies can be found in the BJCP and ACCP and in this BBC report.
General opinion is growing that reducing or stopping drugs in complex older patients is justified in certain situations, where drug cessation rather than prescribing might be beneficial. From a clinical viewpoint, drug cessation seems most justified in four situations, i.e., falls, delirium, cognitive impairment, and end-of-life situations.
Stopping drugs in older fallers was the area most well studied. There is evidence that withdrawal of psychotropics is effective in reducing the rate of falls, and that a regular ‘medication review’ by general practitioners reduced risk of falling.
Studies on drugs cessation in delirium were lacking, however withdrawal of psychotropics and a systematic reduction of polypharmacy resulted in an improvement of cognition.
Very little rigorous research has been conducted on reducing inappropriate medications in patients approaching the end of life. At the end of life, careful assessment of medication is recommended in order to avoid inappropriate treatment and potentially serious adverse drug reactions and events.
In summary, available studies seem to suggest a beneficial impact of cessation of psychotropic drugs on falls and cognitive status. There is a clear need for more work on poly-pharmacy and benefits of medication discontinuation in older patients.
The full paper can be read on the Age and Ageing website.
The latest BGS Newsletter also features the topic of polypharmacy: ”Policy, medical training and clinical practice must adapt to the significant increase in patients taking multiple prescription drugs”. Read the full article here.
What is meant by psychotropics?
A psychotropic is a chemical substance that crosses the blood–brain barrier and acts primarily upon the central nervous system where it affects brain function, resulting in alterations in perception, mood, consciousness, cognition, and behaviour. The following drug classes belong to the psychotropics: antipsychotics, benzodiazepines (anxiolytics, hypnotics and sedatives) and antidepressants.
British Geriatrics Society 
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This is a timely review of an increasingly important area. Sadly, as geriatricians are only too well aware, and as this paper concludes, the population in which polypharmacy occurs most commonly is one in which there is least, if any, evidence for its overall benefit. That said, I would like to make two points: one general, and one more specific.
Firstly, this paper is, as is usually the case, a very iatrocentric view of the problem. It focuses on the technical effects of medications, as measured by doctors. Some drugs ease a given symptom, or symptoms, (such as diuretics in a patient with heart failure). Others are designed to avert or defer an adverse health outcome (e.g. statins and cardiovascular disease). The former usually easily earn their place on the medication list, with the patient understanding exactly what the benefits are, and therefore able to weigh up any side-effects and make a judgement. The latter group have to fight hard to remain, and they depend on the doctor accurately knowing or calculating, and then meaningfully communicating, the magnitude of the risk of whatever the drug is designed to deal with. As Gigerenzer has pointed out, we are not very good at either of these risk-related functions![1] Even if we successfully jump these hurdles, there is still the matter of the patient’s world view and preferences to take into account. The older and frailer the patient, in general, the more symptomatic treatment takes precedence over preventative treatment in my experience of them – with palliative care being the extreme of this spectrum.
Secondly, I take issue with the simplistic and inaccurate statement that HYVET ‘led to a major reduction in stroke and mortality.’ Its overall relative reduction in stroke was trumpeted in the published paper as 30%. However, the NNT was just under 100 over 2 years, for any stroke (fatal or non-fatal). It is of interest that this just failed to reach statistical significance at the 5% level (and this, in a rigorously designed study in ~4,000 people, and with a 90% power to detect a 35% reduction in stroke at the 1% level). Furthermore, the unpublished (but calculable, from the data given) NNT for non-fatal stroke (much more important to most of my patients) was ~450 over 2 years.[2] Most of my patients on multiple medications do not choose to continue this treatment ‘benefit’ when its absolute magnitude is made clear to them! Finally, the fact that the trial was terminated early by the monitoring committee because of reduced mortality in the treatment arm, raises questions as to its face validity, given that this significant mortality effect had not occurred in other trials.
I suggest that there is much room to be more patient-centric in these decisions, to the great benefit of the patient.
Kit Byatt
1. Gigerenzer G. Risk Savvy: How To Make Good Decisions. 2nd ed. 2015. Allen Lane
2. Byatt K. Overenthusiastic stroke risk factor modification in the over-80s: are we being disingenuous to ourselves, and to our oldest patients? Evidence-based medicine. 2014 Aug;19(4):121-122. Available from: http://view.ncbi.nlm.nih.gov/pubmed/24574366